Controversies Related to Discharge Criteria

There is still controversy regarding the requirement for all outpatients to tolerate fluids and void before discharge from an ambulatory surgical facility. It is clearly unacceptable to discharge a patient who is actively vomiting and unable to tolerate oral fluids. Interestingly, Schreiner and Nicolson^[211] found that requiring children to drink before discharge actually increased the incidence of vomiting by more than 50% and delayed discharge. On the other hand, children are more likely to vomit after discharge than during their stay at the surgical facility, and therefore, tolerating clear fluids before discharge may prevent dehydration at home after discharge. At the Children's Hospital of Philadelphia, more than 20,000 day-surgery patients have been discharged home without requiring intake of oral fluids, with no readmissions for dehydration.^[211] All these children (except those undergoing myringotomy tube placement) received the equivalent of 8 hours of intravenous fluid replacement during their hospital stay. Thus, well-hydrated outpatients can be safely discharged home without demonstrating an ability to tolerate oral fluids after surgery.

The requirement to void before discharge has also been challenged. ^[583] The inability to void and urinary retention may be caused by pain (which inhibits normal bladder detrusor function) or by opioid analgesics, spinal or epidural anesthesia, administration of drugs with anticholinergic effects, and prolonged blockade of the autonomic innervation to the bladder.^[52] Patients may be discharged earlier if voiding is not a discharge requirement. Delaying discharge for voiding after spinal or epidural anesthesia with short-acting local anesthetics is unnecessary in low-risk patients (e.g., age <70 years; no hernia, rectal, or urologic surgery; no history of voiding problems).^[583] However, appropriate measures must be in place for urinary

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Before leaving the outpatient facility, patients should have their dressings checked and be given both verbal and written instructions regarding their postoperative care. Most postoperative symptoms (e.g., pain, PONV, dizziness, headache, and myalgias) resolve within 24 hours. However, if these symptoms persist, the patient should be encouraged to contact the facility regarding appropriate follow-up care. All patients must leave in the company of a responsible adult and should be aware of the recommendations regarding appropriate activities after discharge. Patients should be warned to not operate machinery, drive a car, or make important decisions for up to 24 hours after outpatient anesthesia.^[584] However, if short-acting anesthetic drugs are used during surgery, return of fine motor function (driving) can occur within 6 hours.

It is important to have an efficient mechanism in place for admitting outpatients to the hospital. Most well-organized outpatient facilities have an unanticipated hospital admission rate of less than 1%.^{[11] [14]} However, transfer rates are higher in ambulatory centers with a larger proportion of neonates, elderly, and ASA physical status III patients. The Federated Ambulatory Surgery Association multicenter survey suggested that 69% of all perioperative complications occurred after discharge from the ambulatory surgery center.^[585] This finding emphasizes the importance of providing clear, written discharge instructions and the availability of a responsible adult to monitor the patient at home. Most practitioners recommend that out-of-town patients spend their first postoperative night within a reasonable distance from the surgical facility. All outpatient facilities should also have a mechanism in place for collecting follow-up information regarding patient well-being after discharge. For example, nurses at many outpatient facilities telephone the patient the day after discharge to determine the progress of recovery from surgery and anesthesia, whereas other facilities use postcard-type questionnaires for postoperative follow-up.